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Case Law Database

Access over workers' compensation decisions, including En Banc, Significant Panel Decisions, and writ-denied cases.

Case No. MISSING
Regular Panel Decision

Main Evaluations, Inc. v. State

The claimant, Main Medical Evaluations, entered into contracts with the New York State Office of Temporary and Disability Assistance (OTDA) to perform consultative medical evaluations. OTDA terminated these contracts, alleging the claimant failed to disclose professional disciplinary proceedings against its chief medical officer, Arvinder Sachdev, and submitted false information during the bidding process. Following the dismissal of its claim in the Court of Claims, the claimant appealed. The appellate court affirmed the lower court's judgment, concluding that OTDA had legitimate grounds for termination due to the claimant's misrepresentations and failure to report substantial contract-related issues concerning Sachdev's integral role. Additionally, the court rejected the claimant's equal protection argument, finding no evidence of selective enforcement based on impermissible considerations.

Contract TerminationProfessional MisconductFalse RepresentationEqual ProtectionGovernment ContractsAppellate ReviewBreach of ContractMedical LicensingAdministrative ProceedingsDue Diligence
References
5
Case No. MISSING
Regular Panel Decision

55th Management Corp. v. Goldman

This case addresses whether an out-of-court statement made to a court evaluator in an Article 81 guardianship proceeding is protected by absolute privilege, thereby defeating a defamation claim. The defendant, a tenant, made allegedly defamatory remarks about a landlord to a court evaluator during the evaluator's investigation for a guardianship proceeding. The court considered if the remarks were pertinent, if a statement to a court evaluator is considered part of a judicial proceeding, and if the speaker had standing. The court found the remarks pertinent, extended the absolute privilege to statements made to court evaluators given their role as court agents, and affirmed the defendant's standing as a potential witness. Consequently, the defendant's motion to dismiss the defamation complaint was granted.

DefamationAbsolute PrivilegeJudicial ProceedingsCourt EvaluatorGuardianshipMental Hygiene Law Article 81Tenant-Landlord DisputeMotion to DismissCPLR 3211 (a) (7)Scope of Privilege
References
44
Case No. ADJ3465664 (AHM 0133582)
Regular
Jul 23, 2012

MARIA DUARTE vs. GREENFIELD CARE CENTER OF FULLERTON, CAREWEST CLAIMS MANAGEMENT, PEGASUS

The Workers' Compensation Appeals Board granted defendant's Petition for Removal, rescinding the WCJ's prior orders. The WCJ improperly ordered an Agreed Medical Evaluator (AME) to select additional specialists and obtain evaluations, exceeding his authority. The Appeals Board clarified that AMEs cannot designate additional evaluators and that further evaluations must follow statutory procedures. The case was returned to the trial level for further proceedings.

Petition for RemovalAgreed Medical Evaluator (AME)Qualified Medical Evaluator (QME)Off CalendarMandatory Settlement Conference (MSC)Ultra ViresRescind OrderDevelop the RecordAdministrative Director RuleLabor Code sections 4061 and 4062
References
0
Case No. ADJ9866898
Regular
Sep 28, 2018

MARIA GARIBAY vs. CARL KARCHER ENTERPRISES RESTAURANTS, TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA

The Workers' Compensation Appeals Board denied the Petition for Reconsideration in Maria Garibay's case. The denial was based on the finding that the parties failed to follow the mandatory procedure outlined in Labor Code section 4062.2 for obtaining a medical-legal evaluation. This statute dictates a specific process involving agreement or a QME panel selection, which was not demonstrated to have been followed in this case. Therefore, the petition was denied as the necessary procedural requirements were not met.

Workers' Compensation Appeals BoardLabor Code Section 4062.2Medical-legal evaluationQME panelAgreed medical evaluatorPetition for ReconsiderationDeniedDisputed issueRepresented employeeInjury
References
0
Case No. ADJ7199986 ADJ7399845
Regular
Oct 03, 2011

ELMIRA SMITH vs. PACIFIC AUTISM CENTER FOR EDUCATION, TRI- STAR RISK MANAGEMENT

The applicant sought removal to challenge a finding that defendant's requested Qualified Medical Evaluator (QME) panel was properly assigned. The Appeals Board granted removal, rescinded the finding, and determined that *neither* panel was properly assigned. Both panel requests were found to be premature as they were made before the statutory 10-day period for agreeing on an Agreed Medical Evaluator had expired, plus an additional five days for mail service. This decision clarifies the timing requirements for QME panel requests following an unsuccessful attempt to select an AME.

Petition for RemovalQualified Medical Evaluator (QME)Agreed Medical Evaluator (AME)Labor Code section 4062.2(b)WCAB Rule 10507Messele v. Pitco FoodsInc.Premature RequestPanel AssignmentMedical Unit
References
2
Case No. ADJ1679104 (LBO 0387820)
Regular
Aug 26, 2010

GUADALUPE FREGOSO vs. INTEGRAL DESIGN CONSTRUCTION, STATE COMPENSATION INSURANCE FUND

This case concerns a defendant's petition for reconsideration of a permanent disability rating for an applicant injured on August 1, 2006. The defendant argued the rating was erroneous because the administrative law judge (WCJ) instructed the disability evaluator to rate the treating physician's report without referencing the AMA Guides. The Appeals Board denied the petition, finding that the WCJ's instructions were based on the physician's opinion, which complied with the AMA Guides, and the evaluator's rating followed those instructions. The Board also corrected a clerical error regarding the attorney fee calculation.

WORKERS' COMPENSATION APPEALS BOARDReconsiderationFindings and Awardtemporary disabilitypermanent disabilityapportionmentnon-industrial causesindustrial injurynecklow back
References
1
Case No. ADJ10304125
Regular
Oct 04, 2019

EDUARDO VEGA vs. REDWOOD EMPIRE SAWMILL, ZURICH NORTH AMERICA

This case involves a worker seeking to reopen his claim for new and further disability following a 2014 lumbar spine injury. The applicant contended his disability had worsened to permanent total disability, citing vocational expert testimony and medical reports indicating increased work restrictions. However, the Qualified Medical Evaluator (QME) found no change in industrial disability, and his recent evaluation supported the original finding of no new and further disability. The Appeals Board affirmed the WCJ's decision, finding the applicant's vocational evidence unpersuasive without a medical basis for increased disability.

New and further disabilityPetition for ReconsiderationVocational expertPermanent disabilityQualified Medical Evaluator (QME)Petition to ReopenPrimary treating physicianWork restrictionsPermanent total disabilityLabor Code section 5410
References
2
Case No. ADJ3406569
Regular
Apr 09, 2009

JOSEPH NOVAK vs. SIERRA PACIFIC INDUSTRIES, SIERRA PACIFIC REDDING

The Workers' Compensation Appeals Board denied the applicant's petition for reconsideration. The applicant sought penalties and attorney fees, arguing the defendant unreasonably delayed a dorsal column stimulator by undertaking Utilization Review despite a prior Agreed Medical Evaluator's recommendation. The Board affirmed their prior decision, finding the defendant's actions were not unreasonable, as their claims examiner followed proper procedure by initiating UR for a non-routine treatment. The Board cited the Supreme Court's decision in *Sandhagen* to support their conclusion that UR is the appropriate process for evaluating treatment requests.

Workers' Compensation Appeals BoardUtilization ReviewLabor Code Section 5814Labor Code Section 5814.5Agreed Medical EvaluatorDorsal Column StimulatorUnreasonable DelayPenaltyAttorney's FeesSandhagen
References
2
Case No. ADJ7437447
Regular
Jul 31, 2019

EHSAN ALNIMRI vs. SOUTHWEST AIRLINES, ACE INSURANCE COMPANY

This case concerns an employer's alleged discrimination against an injured worker in violation of Labor Code section 132a. The applicant was dismissed from his ramp agent position after conflicting medical reports regarding his work restrictions arose following a back injury. The Workers' Compensation Appeals Board affirmed the administrative law judge's decision, finding that the employer discriminated against the applicant by failing to follow its standard procedure for resolving such medical conflicts. The employer's deviation from its usual practice, including failing to refer the applicant for a company physician's evaluation, constituted unlawful disadvantageous treatment due to his industrial injury.

Workers' Compensation Appeals BoardLabor Code section 132aDiscriminationReconsiderationFindings Award and OrdersPermanent Work RestrictionsPQME ReportTreating Physician ReportDismissalWork Status Conflict
References
0
Case No. ADJ1337418 (GOL 0091701) ADJ850408 (GOL 0091702)
Regular
May 26, 2009

DAWAYNE MOGENSEN vs. SANTA YNEZ RIVER WATER DISTRICT, ACWA/JOINT POWERS INSURANCE AUTHORITY

This case concerns an applicant's claim for reimbursement for an orthopedic bed following a stipulated award for future medical treatment for industrial neck and back injuries. The applicant's treating physician supported the need for the bed for pain relief and improved sleep. However, the Agreed Medical Evaluator (AME) opined that there was no evidence-based research to support the medical necessity of such a bed, which the majority decision followed. The dissenting opinion argues the AME's opinion was not substantial evidence as it was based on a legally incorrect premise that beds are never compensable, and that the treating physician's recommendation, coupled with the absence of a negative guideline, should have been sufficient.

Workers' Compensation Appeals BoardDawayne MogensenSanta Ynez River Water DistrictACWA/Joint Powers Insurance AuthorityADJ1337418ADJ850408Petition for ReconsiderationFuture Medical TreatmentOrthopedic BedDr. Richard Kahmann
References
10
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